Saturday, January 3, 2015

Birth Detective: Why didn't my OP baby come down? Part 2 of 3

This is part 2 of 3, Read Part 1 

Jessica wrote back,

"Hi Gail! 

Thank you SO much for responding.Your time and reply mean so much to me especially as I have been feeling down and out because I felt like "I wish I would have known he was OP etc. and I wish I would have had adequate support to birth how I planned etc."). Here are my answers--


1. Do you have a photo of you baby's molding? That will help me understand his position over the last hours of your labor. Flexed or extended (chin down or up) or posterior or did he rotate? (Photos attached! He did not rotate) [Jessica's answers are here in bold (with her parenthesis) and my comments are here in brick red.]


2. Did you have Pitocin in this labor? Were you offered it? No, I did not want Pitocin going into it. I was offered it at the very end, only when I was on my last hour of labor when he was "stalled" at the 9.5+cm). At that point when I thought about having to go through another several hours of the pain (pushing etc.) I couldn't even imagine so I opted for the C-Section out of sheer exhaustion. [I asked about Pitocin to get a sense of the interventions tried before the cesarean. Adding Pitocin when there is a delay is a common practice, and Jessica was offered it. Pitocin causes stronger contractions if contractions are not considered strong enough to keep a force on the cervix to pull it open like pulling on a t-shirt. Going for stronger contractions isn't the only way to encourage progress, as you see from the many techniques on SpinningBabies.com. Its a step that  Jessica chose to decline. If the baby is stuck against a bone, Pitocin may not help, the baby has to rotate off the bone, flex, or mould to get past a bony protrusion in the pelvis.] 

3. How low in your pelvis, if at all, did your baby get? He was (or at least felt) very low. My OB kept telling me at each appointment how low he was. I think I was at a zero station when I stalled. 
[I always want to know where baby is or was in the pelvis to know more about why baby was stuck. There are two ways a baby may be held back at 0 Station; one is because they face a hip and inside the pelvis a bony protrusion called the ischial spines extends  into the birth space and can catch baby's head, front and back. The other way is if the pelvis is a bit small or the sacrum is brought inwards by a tight muscles/ligaments, which seems to be the case here.]

4. Did you push at all? Whether your body's own urge or directed by the nurse/doctor? Before they knew I was stalled, the nurse asked me to try and push- but at that point my epidural was SO strong, I couldn't feel any urge. The first epidural failed and the second one was SO strong, [numbness from the epidural] went up to my boobs. I had no feeling in my legs and or urges to push. 
[Pushing during (but not between) 3 contractions even before full dilation has sometimes rotated a posterior baby and allowed progress. Push for three (or four) and then stop pushing if rotation doesn't occur. Don't continue pushing on a cervix as it will swell or, not often, rip. But a bit of pushing can make the cervix take the role of the pelvic floor to rotate baby sometimes. Its worth a shot. The epidural in this case didn't help. Could the nurse have gotten more directive? Could the doctor come in at this point and manually rotated the baby with her hand and then let the contractions "labor the baby down" until Jessica had the baby on her perineum and finally then felt a bit of urge to push?  Could the epidural have been turned down or off to see if an urge to push came back?  All this speculation is besides the point that the low white blood cell count indicated an infection present and took away the time to explore these options.

I knew that that is where I went wrong when I got the epidural. I couldn't imagined not getting it with the amount of pain I was in. I needed someone in my face coaching me through it. [A mature and experienced nurse or doula can compassionately, and with a no-nonsense approach do the "Take Charge Routine" explained by Penny Simkin.  Additionally, the side lying release may relieve that crazy pain. 

Instead, after the epidural, I was pretty much on the bed. They turned me from side to side periodically. [Understanding how to open the pelvic diameters for where the baby is will help labor progress. There are some solutions given in the next blog posting.  

5. What size head did your baby have? I am not sure! My husband is a 7.75 hat size. He has a large head. I can find out for you when I call my OB. They should have that on record right? 
[A posterior presentation always makes the head seem larger and fit less easily. A labor stall with a posterior baby with a 12" head is less optimistic for a future vaginal birth after a cesarean than if the baby had a 14" head. But as I've often said, presentation is more important than size, and this would be true here also.]

6. What positions were you in over the last 2.5 hours of labor? On my side -- I was so numb they had to put this air mattress thing underneath me to turn me! I did try hands and knees one time but it was too painful. [There are some techniques to help a baby through the outlet and some maternal positions that open the outlet, like the anterior pelvic tilt and using a peanut ball to open the midpelvis and outlet. Rolling from side to side helps a little but for many stalled labors, more particular movements specific to opening the pelvis at the level baby is stalled is critical.]

Ok, here are more questions of my heart, doula-motivated questions, that may not have as much to do with the outcome directly, but may have directed the course of your decision making. 

Did you feel adequately supported? Yes, I did have a doula. My husband was amazing, but I think I needed more guidance on how or what to do to get through the pain. We needed someone that knew this type of labor and positions/things we could have done to help me progress. [Support by partner, doula AND medical providers and professionals helps give confidence and endurance. In the case of a labor needing an unexpected and unwanted intervention feeling supported helps the emotional resolution. Feeling heard and supported is more important than a good feeling. Support is a basis for the quality of relationship with self and baby.]  

Did you feel stressed at the end and pressured for time? No, I did not feel pressured for time, but I did feel like I couldn't give it another minute I was in so much pain and had trouble breathing with my fever not going down. [An originally undesired intervention can become a rescue. After the crisis, the woman who hadn't wanted the intervention goes back to her original feeling of not wanting the intervention, but now she has had it. How she feels about herself is often mixed with this disappointment. Reframing the view of the intervention in a way that adds compassion to the choice to take it adds self compassion and self acceptance. In Jessica's case, she was in a moment of crisis, more than a moment. Her pain was not adequately addressed as it was beyond the usual labor experience. She was sick. It is so much harder to cope when ill. The first epidural didn't work and was hope dashed. She thought she'd have immediate relief only to continue in pain. The second epidural went high on her spine and gave her the feeling of not being able to catch her breath. Stress was mounting and no one had an answer for her. But no one was saying her time was up. It wouldn't have been typical for her medical team to let her fever continue with the baby unable to come down and no end in sight.  

Did you sleep during the epidural? Barely- maybe for an hour or so. I did not eat anything.
Were you helped to change position during the epidural? Yes- with the air mattress. (not very effective at all) [So no help for coping by sleep.]

Did anyone tell you that you were too tired, or were tiring? I was SO TIRED I had nothing left in my tank. [This is asked to determine if the seed was planted that she couldn't go on. In her case, the fever added to her state.]

And my husband and I own a gym. I workout every day and have strong endurance. Nothing could have prepared me for the pain that I felt with him on my sacrum especially after my waters broke. It was immense. My goal was a natural drug free birth. I got more than halfway so I feel good about that. [Ahh. A big clue that Jessica may have a very strong core, which is code for short pelvic floor. Extra fit bodies may hold a baby posterior and a short pelvic floor resists baby's rotation and descent. Very fit women are often surprised that they have difficulty birthing a posterior baby, if they have a posterior baby. The sacral pain can be associated with tight or short pelvic floor and other pelvic muscles. The sacrum is trying to move but can't. I feel that Jessica got a long way in labor and the solutions for her situation are simply not known by most doulas or nurses. (I'm working on that.)] 

My OB said that my pelvis goes inward a bit and therefore a more limited space for the head to get through... [This may be from a shorter pelvic floor. This may be from a shortened sacrotuberous ligament. Education and body work can address these issues.]

Anyways... Maybe his thought is that if I were to be induced, we would have known his position sooner ... but how would that mean that he would rotate? [I don't think he would have rotated with an induction 24 hours before. He'd have been 1-2 ounces lighter; is that really significant?
 Induction at 39-40 weeks is common when women have providers who seek induction to reduce complications more common with larger babies. One set of complications and compromises are traded for another set and not statistically significant. Cesaresan rates are higher among labors that are induced. 
The birth team didn't know physiological ways to increase midpelvic and outlet diameters. That's established. In part 1 of this series, Jessica says her doctor told her if she would have accepted the recommendation of an induction when it was given the day before she wouldn't have needed the cesarean for an OP baby that didn't rotate.
Does that seem like blaming the mother for the birth teams' lack of skills for OP babies?


My reply back:


"Dear Jessica,
Your answers tell me much!

Now I feel very very confident an induction would not have prevented a cesarean in this situation. 

Yours was just the type of birth that catches both parents and providers unawares - unaware that this is upcoming or what to do once this labor pattern occurs.  I even feel negligent for not educating pregnant parents and the birth world adequately. What if your husband and doula knew where to turn?

This sacral situation is not likely to be something you were born with but rather something that developed at some point in your past.

There is basically one technique that I know of for a tucked in sacrum, maybe two, as I have recently learned a new technique in Australia but I don't know quite yet if it will solve the tucked in sacrum.

  • A tight, short sacrotuberous ligament may have been the deciding factor here.  
  • Perhaps, another lesser factor is a well-developed core strength as a hamper to rotation.

These are "trending" issues with the times and are in no way a woman's fault. People assume "fitness" is a sensible way to ease in birth and what a shock it is when labor is not easy. 

Not just fitness, but myriad twists and turns in the uterine ligaments, sitting positions, even the way we use the toilet instead of squatting, sudden stops or jolts that misalign muscles and ligaments and even the cervix so that baby has a hard time navigating the space. There is ignorance in the birth profession about how the labor pattern and pelvic station reveal the issue. And fewer professionals know what needs to be done for mother and baby to finish such a birth on their own power.

I, myself, am not sure why the sacrotuberous ligament spasms (painlessly) to bring the sacrum deeper in to the pelvis and making the pelvic space smaller. 
It may have to do with a fall, with core strength, tight pelvic floor, or something with the neck and jaw or nose and sphenoid... 
I am seeking more info on the situation of the super fit woman's posterior labor dystocia (stuck labor) which has been one of the trickiest to address. 

I would like to keep the dates known, as 41 and 4 days, following a few days of start and stop contractions is a very important clue that this was not likely due to thyroid issues.

[This start and stop  would be a significant clue if these were the strong contractions lasting over a period of 6-12 hours without changing the cervix. Such a start and stop labor pattern is consistent with a lack of engagement, though not all labors with the baby still above the pelvic brim will express a start and stop pattern.


Jessica did not have the type of start and stop contractions I associate with a lack of engagement. 
Jessica: the OB said that he was Left OP if that makes a difference? 
Gail: Yes, LOP babies may be more likely to engage than the ROP baby. Most LOPs will rotate to LOT and engage in the pelvis. But a few engage while still in occiput posterior. In your son's case, he engaged direct occiput posterior. Once engaged in the posterior, some may rotate lower down the pelvis, and others remain OP, as your son did.]

"Please, Jessica,  also consider if I may please use your son's picture at his birth,... His molding shows he was posterior for sure, which you knew, but many people wonder how to tell after birth if baby was posterior and would learn from seeing his molding. 

He looks so strong. You both worked so hard! I am so glad you reached out to me. You did the best you could in a tough situation and made sensible decisions given the awareness every one had at the time. 

I am quite impressed with how far you got and think that you can surely achieve a vaginal birth and perhaps more easily with some preparation for body balance, lengthening your pelvic floor muscles, and releasing the sacrotuberous ligament from its short, tightness (the key thing here). 

Please know that you faced and solved a very challenging labor. The cesarean is an appropriate choice to end suffering for you and your baby. When labor pain crosses the line from challenging to agony, you get to decide to use that intervention wisely, right!?  

Your baby got some good labor hormones and gut bacteria which are beneficial. That was only possible because you labored before the cesarean. That is a gift you gave your son to be proud of, a compensation for the struggle. It was for something important, as better gut flora is vitally important to the immune system! 



Jessica's reply again:

"What finally did it  in my opinion) [started labor] was a visit to an osteopath that we have here in Sacramento CA (where we live). He is amazing and my husband went to him for a neck issue the day I went into labor. When my husband told him that I was 11 days late, he said for him bring me in for a visit. Needless to say I went in for a visit and in a matter of seconds, he pressed on my (pituitary gland if remember correctly) and my pelvis. I felt an immediate release [Awesome] as if something was unlocked [And it was!]. I even felt a gush of fluid (not water breaking but just more mucous). He promised I'd be in labor about 6 hours later and sure enough I was!! 

He said that he works with pregnant women all throughout their pregnancies to help with ligament tightness and other issues. I wish I would have been seeing him from the start. I definitely will next time around especially now that your email mentions the same thing that he told me about pelvic floor tightness etc. He really is an amazing osteopath."

Gail's Comments here: 
About 1/3 of babies who are posterior at the start of labor (30%, Liebermann) continue to be posterior throughout the labor. The rest will rotate. Because so many eventually rotate, and because cesarean surgery is safer than it was just a few decades ago, the skills to support a posterior labor have waned and skills for surgery have increased. 

Here was a challenge of how to comfort a woman in extreme back labor and how to help her into positions that add comfort and aid rotation. 


Would a forward leaning inversion through 3 contractions have helped reduce pain once the technique was over? 

Jessica faced a very difficult labor made complicated by the baby's posterior presentation. She gave an exemplary effort with few maternal position changes. Hands and knees was not acceptable to her due to the pain she felt in that position. She didn't know her baby was posterior and didn't know which exercises were beneficial to birth compared to gym fitness. 

In my opinion, based on what has helped others with this labor and body description, she really needed her sacrotuberous ligament softened. This is a temporary fix (temporary when done by the lay person) that let's the sacrum swing outward in the middle and lower parts of the sacrum. The baby will drop and perhaps rotate in the added room. 


Gail Suggested: 

"Balance First!
Craniosacral therapy with therapeutic massage by a pregnancy master if possible.
Sacrotuberous release by the doctor, nurse, midwife if possible. The doula can explain it but it may be outside of the doula scope of practice to do this technique, though it can be done externally.
Sidelying release for the muscles supporting the pelvis, including the pelvic floor for pain relief and making "room" for the baby - making flexibility and softening the way.
Alternating the compression/extension of the ASIS and ischial tuberosity in circles that stop in extension (a massage therapist can work this out)
Give Cook's Counter pressure a try on the tuberosities, if on hands and knees or the pubic arch if on back, this helps relax the pelvic floor by giving the stretch receptors of the pelvic floor some slack. (They are stretched already and need some slack for 2.5 minutes at a time.)

"[You might like to n]ow try these techniques:

  • Give Cook's Counter pressure a try on the tuberosities, if on hands and knees or the pubic arch if on back, this helps relax the pelvic floor by giving the stretch receptors of the pelvic floor some slack. (They are stretched already and need some slack for 2.5 minutes at a time.)
  • Lunges during 3 contractions on each side.
  • Dangle through 3-6 contractions.
  • Do not squat.
  • Rope pull from "McRoberts" position if in bed, or 
  • Standing while holding a rebozo or sheet over the head. The sheet is knotted and the knot is thrown over the bathroom door which is then closed. The birthing woman's back is straight and knees are bent. 3-6 contractions. Don't go down so far as to be in a squat until your nurse can see the baby's head.
  • Try pushing for 3 contractions, then rest through 3 contractions without pushing!
  • Rest
  • Do the 3 Sisters and rest again.
[The 3rd Sister particularly] helps relax the pelvic floor by giving the stretch receptors of the pelvic floor some slack. (They are stretched already and need some slack for 2.5 minutes at a time.)


It seems no one at the birth knew how to find and use Spinning Babies Website. Let's get a link out to your sites, blogs, and social network pages to reach more 
birthing and pregnant women and their helpers.


Post on your page to link to Spinning Babies



Next Post in this series, Jessica processes her birth and Gail makes suggestions for the next birth. 

No comments:

Changing the Earth by supporting Birth

Mothers bring forth life; medical corporations do not. Birth can be simple, powerful and loving. Fetal positioning, natural birthing and practical help for normal birth.